Table 4

The guiding principles for the development of the REDUCE maintenance intervention

Intervention design objectivesKey features
To reduce feelings of hopelessness, frustration, self-blame and guilt following a DFU
  • Emphasise target behaviours that patients can engage in to reduce their chances of getting another DFU, while acknowledging that there are precipitating factors (eg, increased age, neuropathy, foot shape) that are out of their control.

  • Enhance patients’ confidence in the target behaviours (eg, by providing a rationale for the necessity of the target behaviours, scientific evidence that behaviours are effective, patient stories and a quiz on the benefits of the behaviours).

  • Validate patients’ feelings of frustration and hopelessness if a DFU does reoccur and avoid arguments that may be viewed as blaming patients for this reoccurrence.

  • Provide links to emotional management techniques that can help people to manage difficult emotions.

To build patients’ confidence in making a self-referral
  • Provide links to foot checking training (eg, by providing information and photographs on what DFUs look like, what signs to look out for and how often feet should be checked with guided practice).

  • Provide reassurance that self-referral is necessary (eg, through a foot health checklist that provides personalised feedback on whether or not patients should self-refer, based on their symptoms).

  • Address concerns around looking foolish or wasting the DFU team’s time when self-referring (eg, (1) emphasise that the DFU team would rather they were contacted early so they are better able to treat any DFUs, (2) provide patient stories about how other patients overcame feelings of burden).

To acknowledge that patients may have physical limitations that make it difficult to engage in foot checking and physical activity
  • Provide guidance on how to check your feet if you have physical limitations, including using a mirror to check the bottom of your feet and asking someone else to check for you.

  • Make intervention content on physical activity optional.

  • Provide guidance about a variety of safe and low impact physical activities to enable patients to find an activity that is suitable for them.

  • Address physical activity concerns all the way through the intervention (ie, in the maintenance intervention and prior initiation phase) (eg, by providing information about the safety of physical activity, patient stories about how other patients overcame these barriers).

To acknowledge that emotional management may not be relevant for all patients
  • Make intervention content on emotional management optional.

  • Emphasise that some people, but not everyone, might experience difficult emotions following a DFU to avoid excluding those who may not relate to this content.

  • Provide a variety of brief emotional management techniques (eg, cognitive behaviour therapy, mindfulness techniques) to allow each person to find a technique that fits with their own personal style of managing emotions.

To ensure patients feel confident in using the maintenance intervention
  • Keep website navigation simple and follow guidelines for maximising website usability.

  • Health professionals at the prior initiation phase will provide technical support, address self-doubts and speak favourably of the digital intervention to encourage use.

  • Encourage friends and family to assist people with website use, if appropriate.

  • Provide a booklet for quick reference and for those who do not have access to the internet.

  • DFU, diabetic foot ulcer.